Originally published in 1991:
DISSOCIATION, 4, 117-123. Reprinted here with the permission
of the copyright holder: Copyright 1991 Dissociative Disorders
Research Publications Limited. All rights reserved. Not to be
copied or distributed in any form without express permission
of the copyright holder.

ABSTRACT

Multiple Personality Disorder (MPD)
can be viewed as a disorder of attachment. Bowlby (1969, 1973,
1980, 1988) described how the emotionally neglected (passively
abused) child detaches from internal and external signals that
would normally lead him to search for a parent; the MPD
literature uses the label dissociation for the same state
which Bowlby called detachment. Upon the detached state are
superimposed the sequelae of active abuse. From this
perspective, many of the problematic transference phenomena in
the treatment of MPD result from reactivation in the
transference of ethologically adaptive attachment behavior.
The patient's difficulties in maintaining boundaries, periods
of sudden withdrawal, and eventual movement through a period
of anxious attachment, represent steps towards internalization
of a secure base of attachment.

One may view
Multiple Personality Disorder (MPD) as an attachment disorder
complicated by the sequelae of "active abuse" (specific acts
which cause physi-cal or sexual harm). When the mother (or
other primary caretaker) is dissociative and detached, the
child is likely to use dissociation as the primary defense
against the overwhelming trauma of "active abuse." The
therapist can note evidence for an attachment disorder in
nearly every aspect of the psychotherapy of MPD. From this
perspective the resolution of the attachment disorder, rather
than the resolution of the effects of sexual and physical
trauma, causes the extended and turbulent nature of the
psychotherapy of more complex cases of MPD.

Varieties
of trauma

Renewed clinical interest in MPD probably
could not have occurred until clinicians accepted that reports
of abuse presented by adult clients were not necessarily
fantasies of the Oedipal or any other variety. As Kluft (1990)
succinctly stated, "The importance of real trauma to the
development of psychopathology is increasingly recognized" (p.
1). Numerous studies of MPD patients, both empirical (e.g.,
Coons & Milstein, 1984; Kluft, 1984b; Putnam, Guroff,
Silberman, Barban, & Post, 1986; Ross, Norton, &
Wozney, 1989) and anecdotal (e.g., Bliss & Bliss, 1985;
Schreiber, 1973), have found a highly significant relationship
between the diagnosis and patient reports of child abuse.
Prospective studies have noted the development of dissociative
symptoms and MPD in children who were being abused (e.g.,
Fagan & McMahon, 1984; Riley & Mead, 1988).
Descriptive theories of MPD also have emphasized trauma as an
etiological factor (Braun, 1984; Braun & Sachs, 1985;
Kluft, 1984b; Ross, 1989; Spiegel, 1986). Going beyond
etiology, scientific writing about MPD treatment has tended to
focus on the direct and indirect (i.e., reenacted) effects of
childhood trauma on the patient's transferences (Barach,
November, 1987; Loewenstein, in press), cognitions (Fine,
1988), and complexity of pathology (Kluft, 1988).

In
addition to the sadistic, invasive, ritualistic, and
humiliating traumatic experiences reported by MPD patients,
clinical material suggests that another kind of childhood
trauma may be ubiquitous. Within the total traumatic
environment (Giovacchini, 1986), another type of trauma, which
I am calling "the parents' failure to respond," profoundly
influences the development of dissociative psychopathology.
Under this rubric I am including (1) the parents' failure to
protect the child from abuse, and (2) the parents' tendency to
dissociate or otherwise detach from emotional involvement with
the child. Though physical neglect can follow (Wilbur, 1985),
the mother's chronic failure to respond to indications of
distress or emotional need in the child is by itself
traumatic, eventually causing a corresponding detachment in
the child. The child's reactive detachment sets the stage for
reliance on dissociation as a response to "active abuse."

Bowlby's theory of attachment

Bowlby's
theory of attachment (1969; 1973; 1980; 1988) is a useful
framework with which to understand the effects of the parents'
failure to respond. He described the survival value to the
species of certain behavioral systems which increase proximity
to the mother as a predictable outcome, thereby protecting the
infant from predators. These systems develop gradually over
the first two years of life as a result of the infant's
"interaction with his environment of evolutionary adaptedness"
(Bowlby, 1969, pp. 179-180). Attachment behaviors, such as
sucking, clinging, crying, following, and smiling, elicit
caretaking behaviors from the mother figure. Caretaking
behavior aids the survival of the species in tandem with
attachment behavior. By picking up, feeding, smiling back, and
so forth, the mother brings the child closer.

Attachment behavior begins at birth (Klaus &
Kennell, 1982) and persists through life. Once a secure
attachment bond forms, the toddler uses the mother as a secure
base for exploration (Bowlby, 1988), returning to her when
frightened. The older infant and toddler can draw upon the
memory of a caretaker, and the knowledge that she always
returns, as the basis for a feeling of security. By age five,
the child normally has concluded the process of internalizing
and symbolizing his secure base, and is able to redirect
attachment behavior onto others, and onto groups (Bowlby,
1973; 1979). Adult attachment relationships realistically
mirror the situation which prevailed during childhood;
obviously, such relationships would be reflected in both the
transference relationship and the therapeutic alliance
(Bowlby, 1988).

Bowlby (1973) identified three phases
of a normal response to separation. The child first protests
the loss and uses attachment behaviors to try and bring back
his mother. When Mother does not return, the child seems to
despair, but still awaits her return. Eventually he seems to
detach and appears to lose interest. However, attachment
behaviors will return upon reunion if the separation has not
been too extended. Following reunion, the child whose parent
has been appropriately responsive to his attachment behaviors
will often cling to the parent, demonstrating anxiety at any
hint of separation.

Bowlby's theory provides a new
perspective on clinging behavior, or separation anxiety. In
contrast to traditional psychoanalytic models which viewed
separation anxiety as a displacement of some other fear
(Bowlby, 1988), Bowlby saw anxious attachment as the result of
real or threatened separations or temporary abandonments by
caretaking figures during childhood (Bowlby, 1973). When a
child knows that an attachment figure will be available
whenever he needs a secure base, he will develop a lifelong
ability to tolerate separations well, and will handle new
situations confidently. Lacking such knowledge, he will
demonstrate anxious attachment and general apprehensiveness at
new ventures.

The availability of an attachment figure
during childhood also influences the person's response to
losses. When a frightened child needs his mother but
ultimately finds that he is abandoned and alone, he protects
himself from further suffering by detaching himself from any
awareness of his feelings and needs. Summarizing studies of
children who underwent prolonged separations, Bowlby (1980)
noted detachment as the final stage of dealing with a
separation. During detachment, the child stops emitting
attachment behavior and even turns away from attachment
figures when they return (as Robertson's [1952] film of a
two-year-old's week long hospitalization and separation from
his parents poignantly demonstrates).

Bowlby saw
detachment as the result of a deactivation of the system of
attachment behavior. By defensively excluding from awareness
"...the signals, arising from both inside and outside the
person, that would activate their attachment behavior and that
would enable them both to love and to experience being loved"
(Bowlby, 1988, pp. 34-25), children experiencing prolonged
separations can block attachment behaviors and its associated
affects. Once established as a defensive process, detachment
then becomes the child's characteristic coping style.

Relationship between detachment and dissociation

My reading of Bowlby's work is that the detachment he
describes is actually a type of dissociation. Although Bowlby
uses the term detachment in describing how children respond to
abandonment, he is really describing a dissociative process.
In its usual definition, dissociation refers to a disjunction
of the association between related mental contents (Braun,
1986; Putnam, 1989; Ross, 1989). It is "[a]
psychophysiological process whereby information--incoming,
stored, or out-going--is actively deflected from integration
with its usual or expected associations" (West, 1967, quoted
in Putnam, 1989, p. 6). Detachment is the same process,
applied to a specific category of sequestered information:
stimuli for attachment behavior.

Detachment protects
the abused child from crying out for help and finding out that
he is alone. In traumatic situations such as "active abuse," a
child feels pain, terror, and other overwhelming feelings.
Such feelings obviously make the child want his mother. But
whether he fantasizes floating away and watching the abuse
from somewhere else, or develops alters in order to
"imagine...that the abuse is happening to someone else" (Ross,
1989, p. 55), the child detaches from the affect. As I will
show later, an abused child has learned to expect no help from
mother because she already had emotionally abandoned the child
on a regular basis.

A case study demonstrates how
detachment is a part of dissociation. Riley and Mead (1988)
describe how MPD developed between ages 2 and 3 in a girl who
was being abused by her biological mother. At 14 months,
before any abuse began, they noted "a strong psychological
attachment...between the child and both guardian parents. She
was also able to let her parents leave the room without
exhibiting anxiety" (pp. 41-42). After visitation with the
biological mother (and abuse) began, she started to cling to
the guardian mother, would awaken during the night to be sure
she was there, and was frightened when left alone with the
examiner. In Bowlby's framework, she showed indications of an
insecure attachment, which is certainly understandable in
light of having been abused when the attachment figure (the
guardian mother) could not protect or comfort her.

Eventually the child moved from anxious attachment to
defensive detachment. She developed an alter, Lila, who dealt
with visits to the biological family. Although she appeared
happy and contented when observed at her biological parents',
she acted as if she did not know her guardian mother (i.e.,
detachment) when the latter made an unexpected visit. Lila's
fascination with peek-a-boo, a game wherein children "play" at
separation, further suggests that attachment issues were
salient.

Evidence of nonresponsivity in the
parents of abused children

Several sources of data,
reviewed below, suggest that the parents of neglected and
actively abused children fail to be emotionally available to
their children. In some of the sources, the relationship
between the parents' failure to respond and the child's
detachment is also clear.

Injured children.

When a child gets hurt, varying degrees of parental
negligence can exist, ranging from complete innocence to
calculated sabotage. The dissociative or pre-occupied parent
is more likely to have a child wander away into a dangerous
situation while her attention is "otherwise engaged."

A study cited by Bowlby (1973) of children injured in
traffic accidents in one section of London is a case in point.
Almost two-thirds of the children had been alone; among
younger children, more than half had been alone. Bowlby also
summarized two studies of the family backgrounds of children
injured in traffic accidents, and one study of the families of
children who had been burned. Compared to a control group, the
injured children in all three studies were more likely to be
unwanted or unloved, or to have a mother absorbed with other
family problems. In such families, it would be easy for a
forgotten child to wander out the door and into the street, or
to get near a hot stove.

Emotionally detached parents.
Furman and Furman (1984) described parents who
"intermittently decathect" their children. These parents
periodically seemed to withdraw from their emotional
investment in their children, either out of depression or as
an expres-sion of conscious or unconscious anger. The writers
often found this kind of dysfunction in the parents of
preschoolers who had been molested or raped. Seeming to refer
to extrafamilial molestation, they commented, "Children this
young are rarely left in situations that will eventuate in a
sexual molestation if their parents have an unremitting
investment in them" (p. 427). They also found intermittent
decathexis to be common in parents whose children tended to
"get lost."

Furman and Furman noted that the parental
dysfunction was reflected in the child's own tendencies to
withdraw attention from others and to be on "cloud nine,"
which are dissociative behaviors. In analysis, the children of
intermittently decathecting parents were extremely sensitive
to the analyst's withdrawal due to internal preoccupations; in
my clinical experience, MPD patients demonstrate the same kind
of sensitivity.

Clinicians observed a similar pattern
of parental detachment in the mothers of some developmentally
delayed infants. Fraiberg, Adelson, and Shapiro (1974/1987)
provide a painfully vivid description of a dissociative mother
and her child's detachment. The mother had been grudgingly
parented by relatives after her mother's postpartum suicide
attempt, and had been sexually abused by her father and a
cousin. During a testing session, her baby begins to cry.
It is a hoarse, eerie cry in a baby...On tape, we see the baby
in her other's arms screaming hopelessly; she does not turn to
her mother for comfort. The mother looks distant,
self-absorbed. She makes an absent gesture to comfort the
baby, then gives up. She looks away. The screaming continues
for five dreadful minutes on tape. In the background we hear
Mrs. Adelson's voice, gently encouraging the mother. "What do
you do to comfort Mary when she cries like this?" [The mother]
murmurs something inaudible...As we watched this tape
later..., we said to each other incredulously, "It's as if
this mother doesn't hear her baby's cries!" (pp. 104-105; the
emphasis is mine)

Psychoanalytic case study of
adults who were raped as children.

Katan (1973)
discussed six adult analysands who reported having been raped
as children. In one case, the patient's mother,
disappointed in her marriage, had turned to social
activities. Bridge was so important to her that she had little
time for her children...A succession of nursemaids took
complete care of the little girl and also shared a room with
her...The mother['s] interest in the child concentrated on
toilet training...The nursemaids...did not pay sufficient
attention to the child to protect her against overwhelming
sexual assaults [e.g, oral rape by the nursemaid's
boyfriend]...Mother frequently excited the child by inviting
her into the bathroom while taking a bath. These were the only
times the patient remembered getting her mother's attention.
(pp. 216-217)

In a second case, the patient's parents
worked all day, and the mother "returned in the late
afternoon, worn out and irritable, to do household chores
which she despised. Her patience with her children was very
limited. Yelling and spanking were her only means of
upbringing" (p. 210). When the father fondled the child and
also bit her, the mother expected the child to protect
herself. When the patient was five, she was orally raped at
school, and recalled her mother saying, "She is damaged for
life...nobody will ever want her" (p. 212). Katan commented,
"Some of my patients...had the tendency to expose their own
children to the same experience, mostly by not protecting them
when they should have been protected" (p. 220).

In
treating mothers who have come for supportive therapy when
their children have been sexually abused, my colleagues and I
have found dissociative behaviors and even MPD in a notably
high proportion of the cases.

MPD patients as
parents.

MPD patients are by definition dissociative.
If it can be shown that their symptomatology causes them to be
intermittently unavailable to their children, they present the
researcher with an opportunity to study the effects of
disengaged parenting on children. Kluft (1987) reported on the
parental fitness of a group of 75 females with MPD, based on
the patients' descriptions of their own behavior. In this
study, Kluft did not report on the functioning of the
children. Among the pathological parenting behaviors found in
the entire sample were "impairment due to amnesia" (20%),
"Abdication of parenting by alters" (17.3%), and "affective
absence" (5.3%). Due to amnesia and the wish to please the
interviewer, these percentages may be too low. Sixteen percent
of the mothers admit-ted to having physically or sexually
abused their child, or failed to protect the child from
physical injury. Kluft classified over 45% of the mothers as
"compromised impaired"; although they were not abusive, their
symptoms interfered with their functioning as mothers, or they
failed to act in the best interests of their children.

Kluft (1984a) discussed one child with MPD whose
father was dissociative and whose mother had MPD. Although
there was no evidence of abuse by either parent, the child
presented a classic MPD picture (with amnesia); the
precipitating event was a near-death drowning. Kluft did not
discuss the specific parenting style to which the boy had been
exposed.

Coons (1985) found a significantly greater
percentage of emotional distur-bance in the children of MPD
patients as compared to the children of a matched sample of
non-dissociative psychiatric patients. Although the study did
not specifically explore the parenting styles of the MPD
patients, "eight of the nine emotionally disturbed children
had mothers who continued to dissociate and/or were poorly
motivated for therapy" (p. 160).

Though the available
data is sparse, the existing studies suggest that parental
dissociation is associated with childhood psychopathology.

MPD patients' descriptions of parental failure to
respond.

Wilbur's (1985) description of non-nurturing
abuse summarizes the emotional and physical neglect that many
MPD patients describe. Putnam et al. (1986) found that over
60% of their case series of 100 MPD patients reported extreme
neglect in childhood.

Any therapist working with MPD
patients hears daily examples of parental non-responsiveness.
Whether these memories reflect literal events or merely
symbol-ize the patient's emotional experience, they show the
prevalence of neglect as a theme in the emotional life of MPD
patients. Many patients report that their mother was
periodically depressed to the point of being bed-ridden, was
hospitalized for depression, and/or received ECT. One
patient's mother "always burned all the food," having been so
dissociative that she lost time whenever she tried to cook.
Some parents rarely attended school functions, showing little
interest in academic progress. Commonly, patients report that
their mothers pushed them away or punished them when they
cried, told them that their problems were insignificant, or
locked them in their rooms or a closet until they stopped
crying. One patient reported that her mother sat and watched
TV while her father raped another child in the next room.

Summary of the evidence.

Several
converging data sources (in addition to what patients have
remembered) indicate that abused children commonly receive
preoccupied, dissociative parenting. When children have been
injured in accidents, or victimized by extrafamilial incest,
their parents tend to have been "intermittently decathecting"
(detached), unloving, or entirely rejecting. When parents have
been detached from their children (or unavailable to protect
them from injury, as in the case of Lila; Riley & Mead,
1988), the children demonstrate the pattern Bowlby called
detachment: an active turning away from the abandoning parent,
and a withdrawal to a dissociated state. As parents, they
often reenact the parenting they received: they are unable to
protect their own children from abuse, and they dissociate
when their children need them.

Transference
phenomena reflecting the parents' failure to respond

Given the presence of detachment as a dynamic in MPD
patients and their parents, one would expect to find many
representations and reenactments of attachment-related issues
in the treatment of MPD. The attachment issues are more
prominent in relatively complex patients with many alters
(Kluft, July, 1991, personal communication). An awareness of
attachment issues can drastically shift one's perspective on
what clinicians usually call "dependency." Thus, Putnam's
(April, 1990) description of intrusive abuse, leading to a
lack of boundaries, as "the core problem" in MPD, changes to
an awareness that the alternation between intrusion/assault
and abandonment is the core problem.

Attachment issues
sometimes become evident through the use of detachment in
early sessions. Because MPD patients often enter therapy
feeling that no human can be trusted, they use various
protective mechanisms to get the help they need without having
to develop a sense of trust. Some patients will immediately
produce child alters who seem to trust and cling to the
therapist, but they are quickly replaced with distant or
hostile alters who protect the personality system from the
expected assault. Using attachment behavior as a framework,
one can reconceptualize this sequence as representing the
reactivation of attachment behavior in the transference.

Early in treatment, when the patient is often flooded
by signals that internal and external danger is close at hand,
the need for an attachment figure is strong. Bowlby would
remind the therapist that attachment behavior is elicited by
fear, and that the frightened person seeks proximity to an
attachment figure. Thus, there are frequent emergencies, phone
calls, requests for extra sessions, requests for
hospitalizations or medication (symbolic feeding).
Alternatively, patients run from their attachment wishes by
self-destructive behaviors or by dropping out of treatment.
When they later reenter treatment, they commonly say that they
felt they were "getting too close."

Caretaking
behavior, as well as attachment behavior, is ethologically
determined. Not unexpectedly then, the attachment behavior of
child alters can readily elicit caretaking behavior from the
therapist. The therapist new to MPD may be surprised by the
intensity of his wish to respond to the attachment behaviors
of the child alters. This behavior sequence has usually been
discussed in the MPD literature from the equally valid
viewpoint of countertransference-based violations of the
patient's boundaries (e.g., Barach & Comstock, November,
1990; Chu, 1988; Greaves, 1988). Eventually, the therapist
realizes that any caretaking behavior must be applicable to
the needs of the system as a whole.

While the tendency
of some MPD patients to violate the therapist's boundaries has
usually been understand as the transference reenactment of
abuse (Barach, November, 1987; Loewenstein, in press),
boundary violations also reflect the reactivation of
attachment behavior within the transference. For example, some
patients monopolize the therapist's answering machine, spend
hours in the therapist's waiting room, leave notes on the
therapist's car, drive by the therapist's house, etc.

There are positive and negative aspects to this kind
of acting out. The positive aspect, as Winnicott (1965)
pointed out, is the patient's hope that the original trauma
can be corrected, that this time she will not be abandoned.
The reactivation of attachment behavior also raises the
possibility that the adult patient may eventually develop an
internal sense of security in her attachment and will not need
to detach (i.e., dissociate) in response to internal and
external demands. As Greaves (1989) said, "the external
reference point of the therapist becomes a place of focus for
the patient's emotions in the external object world, hence a
vehicle of eventually-integrated experience" (p. 225).

The negative aspect to the reactivation of attachment
behavior is that the patient may see the therapist's empathic
neutrality as an abandonment which is more real than
transferential, thereby wrecking the therapeutic alliance. The
patient often unconsciously perceives the therapist as
unresponsive, as her mother was. To protect herself from
anticipated future abandonments, the patient may then move
into a state of detachment, often by calling upon an
intellectualized or numb alter. The expression of dissociated
anger which eventually follows, accompanied by further demands
(Barach & Comstock, November, 1990), can push the
therapist into detachment or retaliation. Anger at the
departed attachment figure is a common response to separation,
which may have the function of overcoming obstacles to reunion
and making it less likely that the attachment figure will
leave in the future. But repeated experiences of separation
and loss are likely to elicit malicious, dysfunctional anger
from the one who has been left, weakening the attachment bond
instead of strengthening it (Bowlby, 1973). Indeed, the MPD
patient who is furious at the therapist's unwillingness to
fulfill every demand is often terminated, medicated, or
hospitalized--in other words, "sent away" in one manner or
another.

Early in treatment, MPD patients usually
demonstrate either separation anxiety or detachment when a
therapist leaves for vacation. I cannot recall any MPD patient
who has ever been able to retain positive feelings over an
extended absence without separation anxiety (the fear that the
therapist will not return) or detachment. Many MPD patients
find that they are unable to picture the therapist in their
mind when he is out of town or out of the office. Some
therapists have resorted to giving the patient a transitional
object to remind her of the therapist during a vacation, but
the ability of the object to evoke a sense of security tends
to wane after a few days; in other words, detachment sets in.

If treatment progresses well, a few alters begin to
develop a sense of security in their attachment, which may
then spread throughout the system of alters as integration
nears. At first, the attachment bond is concrete in nature and
requires picturing the therapist, fantasizing about the
therapist, having imaginary conversations with the therapist
as issues come up, talking to other people about the
therapist, etc. The traditional derogatory term used for this
period of the therapeutic work is "dependent," or "regressed."

In the conceptual framework of attachment theory, such
developments are an extremely positive sign, showing that the
patient has entered a period of anxious attachment. As Bowlby
(1969, 1973) noted, anxious attachment following detachment is
a sign that defensive exclusion of the need for proximity to
an attachment figure has been breached; anxious attachment
thus indicates a departure from the use of dissociation as a
defense mechanism. Gradually, but not always steadily, the
patient begins to find the therapist to be a secure base to
which she can return when frightened. The patient's nascent
sense of security then makes the stress of abreactive work
bearable. Often the patient begins to make major gains in
self-confidence at this time. The therapist should not
discourage attachment, but should maintain his attitude of
empathic neutrality. He should encourage the patient to
express wishes for dependence and attachment just as he
encourages expression of all other feelings, but he should not
endeavor to gratify those wishes other than by his steady,
nonjudgmental, mirroring presence.

Not all MPD
patients seem to be able to develop a secure base for
attachment. Some seem to get stuck in the period of anxious
attachment, while others, staying with the use of detachment,
never invest in the therapeutic alliance. Many of these
patients demonstrate the pattern which Kernberg (1984) called
malignant narcissism.

However, as many MPD patients
move towards integration, they gradually develop an
internalized sense of security which is much less dependent on
the actual or imagined presence of the therapist. The feeling
of internal security is available to the personality system as
a whole, and patients will often make forward strides in their
lives which they previously feared to attempt.

Clinical example

Ann (a pseudonym) came
into treatment complaining of chronic anxiety. She was having
panic attacks in numerous situations in which she could find
no external danger. With people she was either seductively
compliant or sarcastic; she left the impression that she could
"take or leave" the people in her life, including the
therapist. She made little eye contact and did not seek
comfort when distressed. In other words, the clinical picture
showed detachment. As treatment progressed, Ann described
dissociative symptoms. Gradually the diagnosis of MPD was
made.

Ann was sure that the therapist would forget her
in between sessions and when he took a vacation. In other
words, she expected that she would disappear from the
therapist's mind as she had disappeared from her mother's. The
first attempt to establish a continuity of attachment came
from a child alter who asked the therapist to keep a small toy
that was important to her. She could picture in her mind that
the toy was still with the therapist, even though she could
not yet imagine that her mental representation stayed with
him. Ann was highly sensitive to the therapist's momentary
wandering of attention. She tended to become more detached and
numb when this would occur. Eventually, Ann's sudden
detachment sometimes alerted the therapist to the fact that
his thoughts had begun to wander, and was a helpful indicator
that countertransference issues needed exploration.

After abreactive work began, Ann went through a period
of making numerous calls to the therapist. These calls, at
reasonable hours, were usually not crisis calls (suicide,
intrusive flashbacks, self-mutilation, etc.). Rather, they
reflected moments of separation anxiety, when the patient
wanted to check if therapist "was still there." Listening to
the therapist's answering machine later sufficed. The patient
also used imagined conversations and interventions from the
therapist (pictured in great detail and involving
age-appropriate comforting of the relevant alters) to cope
with situational transitions and anxieties. At times Ann had
sudden upsurges of denial concerning parental abuse; these
tended to occur when she strongly feared losing the attachment
bond to her parents. Her internalized sense of self-confidence
developed and she found friends, a career direction, and more
willingness to try new ventures.

Ann did not work
directly on material related to her mother's failure to
re-spond until after the active abuse had been processed. She
allowed herself to feel much younger than ever before in the
treatment, accompanied by intense sadness and mourning. She
used her internal "secure base" and the therapist as sup-ports
for her mourning, no longer needing the therapist to quell
separation anxiety. Although she felt intense sadness, she did
not dissociate from it or detach from those around her; she
knew why she was sad, and accepted these feelings as her own.

Summary

Though the effects of active abuse
on the etiology of MPD are important, attachment issues are
the central part of the disorder. Just as the mother's failure
to respond to and protect her child affected every
developmental task, so do attachment issues affect every
aspect of the treatment. The achievement of an internalized
secure base allows the MPD patient to abandon dissociation as
a coping style, so that she can feel a part of her world.

References

Barach, P. M. (November,
1987). Transference reenactments of child abuse in the
treatment of multiple personality disorder. Presented at the
Fifth Conference of the International Society for the Study of
Multiple Personality/Dissociative States, Chicago.

Barach, P. M., & Comstock, C. (November, 1990).
The effects of altering the treatment frame during ongoing
treatment of multiple personality disorder. Presented at the
Fifth Conference of the International Society for the Study of
Multiple Personality/Dissociative States, Chicago.

Winnicott, D.W. (1965). Psychotherapy of character
disorders. In Winnicott, D. W. The maturational processes and
the facilitating environment: Studies in the theory of
emotional development (pp. 203-216). New York: International
Universities Press.